HomeMy WebLinkAboutBLDG-24-361 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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a=f= CITY ',tCxr.l-.a,/i-1-"` MA DATE (,,),21Z `-( PERMIT# QL06-24- ICf
JOBSITE ADDRESS 2 Lis.d 4,:3 OWNER'S NAME
GOWNER ADDRESS TEL
TYPE OR FAX��
p t OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
CLEARLY NEW:VRENOVATION:❑ REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 4 5
BOILER 68 i 9 10 11 12 13 �.
BOOSTER _
CONVERSION BURNER
COOK STOVE ( L
DIRECT VENT HEATER
DRYER
FIREPLACE (
FRYOLATOR
FURNACE
GENERATOR
GRILLE •
INFRARED HEATER
LABORATORY COCKS _
MAKEUP AIR UNIT =
OVEN _ _
POOL HEATER R E � � F D
ROOM/SPACE HEATER _ ___...
ROOF TOP UNIT
TEST JUN 1 2
UNIT HEATER _
INVENTED ROOM HEATER J J O NC -. nitrMr n T
WATER HEATER " T
OTHER
INSURANCE COVERAGE
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES DID 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er OTHER TYPE INDEMNITY ❑ BOND 0
OWNERS INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
J SIGNATURE OF OWNEP.OR AGENT CHECK ONE ONLY: OWNER CI AGENT 0
is I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the parrot issued for this application will be in compliance with elPertinent provision of the
Li) Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t ) -
PLUMBE ASFITTERNAME LICENSE# t3�LSIGNATURE
MP MGF❑ JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC 0
COMPANY NAME CI•5:('t\-( Q�\A ADDRESS I °t .SQL--- -- v----
CITY )--1t 9(-.l<+_ STATE )'v ZIP CDZt- k"1 TEL 9t.15--Ste1 —`-( 'C
FAX CELL
EMAILC3J rrL(it pW-,..11;...-D ti+' c4m(. cp---,
�tOUGI3 GAS PECT ON E.
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
`(es No •
THIS APPLICATION SERVES AS THE PERiu1IT ❑ ❑
• FEE: $ PERMIT# •
PLAN REVIEW NOTES